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High Frequency Ultrasound Assessment of Labial Glands

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High Frequency Ultrasound Assessment of Labial Glands Original paper Cite as: Skrzypek E, Mlosek RK: High frequency ultrasound assessment of labial glands High frequency ultrasound assessment of labial glands simulating smallsimulating nodules small or nodulesgranulomas or granulomas after lip augmentation after lip augmentation. J Ultrason 2020; 20: e261–e267. doi: 10.15557/JoU.2020.0046. Submitted: High frequency ultrasound assessment of labial glands 27.09.2020 Accepted: simulating small nodules or granulomas after lip 07.10.2020 augmentation Published: 18.12.2020 Ewa Skrzypek1, Robert Krzysztof Mlosek2 1 Department of History of Medicine, Medical University of Warsaw, Poland 2 Ultrasound Diagnostic Department, Faculty of Medical Sciences, Medical University of Warsaw, Warsaw, Poland Correspondence: Ewa Skrzypek, MD, PhD, Department of History of Medicine, ul. Litewska 16, 00-575 Warsaw, Poland; tel. 48 604 075 561, e-mail: [email protected] DOI: 10.15557/JoU.2020.0046 Keywords Abstract lips, Aim of the study: The aim of this study is to evaluate the utility of high-frequency ultrasound fillers, in the assessment of the nature and differentiation of lumps occurring in the labial mucosa complications, after lip filling procedures. Material and methods: The study sample included 5 women aged labial glands, from 28 to 43 years (mean age: 37.4 years) who previously underwent a lip augmentation or high-frequency rejuvenation procedure. Photographic documentation was taken and high-frequency ultra- ultrasound sound assessment was performed in all the patients. The presence of deposits, foreign body granulomas, fibrosis and labial glands was mainly investigated taking into account the shape of the abnormalities, their margins, surface area, location and echogenicity. In order to con- firm the diagnosis, histopathological examination was performed. Results: The examinations performed made it possible to differentiate between granulomas and persistent deposit nod- ules and to demonstrate the presence of massive fibrosis and of labial glands pushed out by these abnormalities with the glands presenting as hypoechoic oval areas. Histopathological examination confirmed the morphology of labial glands reported by the patients as uncom- fortable lumps felt from the side of the mucosa, which clinically simulate persistent deposit nodules or granulomas. Conclusions: High-frequency ultrasound is a method that is essential for the correct differentiation between complications of tissue filler procedures. This, in turn, makes it possible to apply the right treatment. In this study, it was demonstrated for the first time that the lumps reported by patients who have had a lip filling procedure may be the result of labial glands being pushed out by deposits, granulomas or massive fibrosis, which are complications of such procedures. Introduction have a negative effect on the quality and structure of the skin. External factors, including the impact of the envi- Lips are a very important part of facial attractiveness. ronment, exposure to UV radiation or smoking result in a From time immemorial, mainly women have enhanced change of skin integrity. their lips as an indication of youth, beauty and sensual- ity(1,2). Ideal lips are full with well-defined vermilion bor- For this reason, lip augmentation, and thus rejuvena- der. Passage of time and the associated subcutaneous adi- tion using fillers, in recent years mainly those based on pose tissue atrophy, loss of elasticity, effects of gravity and hyaluronic acid (HA), has become a very fashionable and the remodelling of the skeleton and muscles lead to the widely available procedure. When performing this pro- ageing of this area. Beginning in the third decade of life, cedure, one should always take into account the context internal factors such as hormonal and genetic changes of the whole perilabial area set by the base of the nose, © Polish Ultrasound Society. Published by Medical Communications Sp. z o.o. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial- NoDerivatives License (CC BY-NC-ND). Reproduction is permitted for personal, educational, non-commercial use, provided that the original article is in whole, unmodified, and properly cited. e261 Ewa Skrzypek, Robert Krzysztof Mlosek the cheeks and the chin. From the aesthetic point of view, Material and methods the right proportion between the upper lip and the lower lip is also important, which is 1:1.6 in young Caucasian The study sample included 5 women aged from 28 to 43 women(1,2). years (mean age: 37.4 years) who sought medical help for a complication after a lip filling procedure: they com- There is a rich market of products for reducing any signs plained of small lumps felt from the side of the mucosa of of lip ageing, which include implants, botulinum toxin, both lips, which were sometimes uncomfortable during laser treatments, micropigmentation and fillers, which lip movement. In all the patients, the changes were pre- are the most widely used and most popular solution. viously clinically diagnosed as nodules or granulomas. Fillers play an important role in lip and perilabial area rejuvenation. Photographic documentation were taken and the lip mucosa was palpated. Detailed analysis of the study sample Unfortunately, due to the lack of an ideal filling sub- is presented in Tab. 1. stance, a significant increase in the number of proce- dures and cases when they are performed by unauthor- Subsequently, ultrasound examination was performed ised individuals, there has been a growing number of using the Philips Epiq 5 ultrasound scanner (Philips, complications. Bothel, USA) equipped with an L18-5 broadband linear transducer set to the lowest imaging depth and highest The most common complications of lip filling procedures resolution and the DermaMed high-frequency ultrasound include nodules that are deposits of the filling material and scanner (Dramiński S.A., Olsztyn, Poland) equipped with a foreign body granulomas (FBG). They are very difficult for 48 MHz mechanical sector transducer. clinical differentiation, especially since aesthetic medicine clinics offer a very limited range of tools for diagnosing Next, histopathological examination was performed of complications. small nodules surgically removed from the side of the oral mucosa. The specimens were preserved in 4% buffered for- High frequency ultrasound (HFUS) turns out to be the malin, embedded in paraffin, cut into 4 μm pieces and rou- only effective and non-invasive method for diagnos- tinely stained with haematoxylin and eosin, and additionally ing complications of lip filling procedures. It currently with Alcian Blue pH 2.5 and Periodic Acid-Schiff (P.A.S). makes it possible to differentiate between deposits and granulomas, as well as any other doubtful cases in which diagnosis based on exclusively clinical evidence is simply Results impossible(3). In patients complaining of small lumps felt from the side The aim of this paper is to assess the utility of high-fre- of the mucosa of both lips occurring after lip filling proce- quency ultrasound in the evaluation of clinical diagnosis dures, which were often uncomfortable to them during lip of small nodules or granulomas after lip filling proce- movement, clinical examination involving palpation con- dures. What is particularly important is that histopatho- firmed their presence (Fig. 1). logical studies also confirmed the morphology of these abnormalities observed on ultrasound, similar to an In nearly all cases, ultrasound examination of the lips dem- earlier study on the differentiation between nodules and onstrated filler deposits; in 3 cases, it showed hyaluronic granulomas(3). acid deposits presenting as anechoic focal abnormalities, Tab. 1. Characteristics of the study sample Time to Ultrasound No. Age at complication Lump site Filler type complication (years Clinical diagnosis diagnosis from procedure) nodules or massive fibrosis, 1. 38 upper lip unknown 12 granulomas labial glands massive fibrosis, nodules or 2. 40 lower lip HA a few times 5 labial glands catching granulomas on the incisors lower lip, nodules or persistent deposits, 3. 28 HA a few times 4 upper lip granulomas labial glands granulomas, upper lip, nodules or 4. 43 PAAG 12 persistent deposits, lower lip granulomas labial glands upper lip, nodules or deposits, granulomas, 5. 38 HA twice 1 lower lip granulomas labial glands HA – hyaluronic acid; PAAG – polyacrylamide hydrogel e262 J Ultrason 2020; 20: e261–e267 High frequency ultrasound assessment of labial glands simulating small nodules or granulomas after lip augmentation usually oval in shape, with sharp, regular external mar- gins. They were usually accompanied with the indentation of the orbicularis oris muscle and minor salivary glands being pushed out, which are seen as hypoechoic, oval, well- defined areas located just below the oral mucosa on exami- nation with the Epiq 5 machine (Fig. 2). In one case, the pushed out glands caught on the teeth, thus being at risk of irritation (Fig. 3). The use of permanent fillers is usually complicated by granulomas observed on ultrasound as fairly irregu- lar, oval focal abnormalities, sometimes with blurred, uneven external margins. In the present cases, however, the authors observed small labial glands bulging into the oral cavity in the projection of the granulomas mentioned above. Labial glands can also be pushed out by massive fibrosis in the lips observed by the present authors, caused by numerous lip filling procedures, including those using
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